Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2004  |  Volume : 10  |  Issue : 1  |  Page : 34-36
An unusual cause of acute abdomen in an adolescent

Department of Surgery, Prince Charles Hospital Merthyr Tydfil CF47 9DT, Wales, United Kingdom

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Date of Submission20-Aug-2002
Date of Acceptance26-Jun-2003

How to cite this article:
Al-Samarrai AI. An unusual cause of acute abdomen in an adolescent. Saudi J Gastroenterol 2004;10:34-6

How to cite this URL:
Al-Samarrai AI. An unusual cause of acute abdomen in an adolescent. Saudi J Gastroenterol [serial online] 2004 [cited 2022 Dec 7];10:34-6. Available from:

Primary duodenal ulcer disease occurs in children of all ages, but is most often seen in those over ten years. As in the adult, it often pursues a chronic course. Primary gastric ulcer is seen in children under 6 years, is more unusual, and does not tend to recur. Stress ulcers are seen most often in infants and in critically ill children and are asymptomatic until the complications of haemorrhage or perforation appear [1] .

   Case report Top

A 14-year old boy presented with acute upper abdominal pain of six hours duration. His blood pressure, pulse and temperature were normal. His complete blood picture showed a leucocytosis while his urea ,electrolytes and serum amylase were within normal range. Clinical examination revealed marked tenderness over the whole abdomen but mainly in the epigastric region with guarding. Plain Chest X-ray showed gas under the diaphragm [Figure - 1]. On clinical grounds and the plain x-ray it was clear we were dealing with perforated viscus. Although gas under the diaphragm can occur with any perforated viscus, sub diaphragmatic gas under the right side is usually pathognomonic of gastric or duodenal perforation. Hence it was not necessary to do further investigation such as ultrasound especially as we practice diagnostic laparoscopy in our unit.

At laparoscopy, bile and fibrinous adhesions were found around the stomach and the duodenum. It was not possible to see the site of perforation, but there was free bile in the pelvic cavity. So laparotomy was performed, which revealed a perforated prepyloric ulcer, which was closed with an interrupted suture and an omental patch was used to cover the site of the perforation [Figure - 2]. The patient had an uneventful postoperative period. His blood was positive for H. pylori and he was put on triple therapy He is due for follow up endoscopy.

   Discussion Top

The prevalence of H. pylori infection varies widely by geographic area, age, race, ethnicity, and socioeconomic status. Rates appear to be higher in developing than in developed countries, with most of the infections occurring during childhood, and they seem to be decreasing with improvements in hygiene practices. H. pylori causes chronic gastritis and has been associated with several serious diseases of the gastrointestinal tract, including duodenal ulcer and gastric cancer. Food prepared under less than ideal conditions or exposed to contaminated water or soil may increase the risk. Overall, inadequate sanitation practices, low social class, and crowded or high-density living conditions seem to be related to a higher prevalence of H. pylori infection [2] . The pattern of clinical H. pylori disease found within a population is determined by the age of acquisition of the infection; infection in childhood leads to a predominance of gastric ulcer and gastric cancer, whereas infection in adulthood allows duodenal ulcer to predominate and gastric cancer is rare. H. pylori spreads rapidly among families with children but not in those without, suggesting that children might be involved in the transmission of the infection [3] .

The history of peptic ulcer disease in infants and children dates back to 1826 with a description by Von Siebold of perforated gastric ulcer in two days old infant. Reports from other series have continued to suggest that peptic ulcer occurs more frequently in childhood than has been reported and should be given more clinical consideration in paediatric practice [4] . Primary peptic ulceration is no longer regarded as a rare disease of childhood, but its exact incidence and pathogenesis remain debatable. Authors have described two children of age 11 and 12, who presented with a perforated primary gastric ulcer [5],[6] . Drug-related ulcers are being seen more frequently as the use of nonsteroidal anti-inflammatory agents increases. With the use of new therapeutic agents, management has been simplified and surgical intervention has become a rarity. Helicobacter pylori is now a recognized cause of antral gastritis and ulceration in the child [1] . Duodenal ulcers associated with H. pylori are seldom seen in children under ten years of age [7] . Surgical complications of ulcer disease in children and juveniles reviewed in 36 patients showed perforation in 30 cases, bleeding in 4 cases, a combination of penetration of ulcer into the pancreas head with bleeding in one case and in another case perforation of gastric ulcer with bleeding [8] .

   Conclusion Top

Primary peptic ulceration is a common disease of childhood, although the incidence and pathogenesis remain debatable: What is clear is that H. pylori infection rarely resolves spontaneously and that the chronic gastritis that accompanies infection is typically maintained for the duration of infection. Ultimately, if untreated, this chronic inflammation predisposes a subset of individuals to develop gastric or duodenal ulcers and even gastric cancer.

   References Top

1.Gryboski JD. Peptic ulcer disease in children. Medical Clinics of North America 1991; 75, 889-902.  Back to cited text no. 1    
2.Brown LM. Helicobactor pylori: Epidemiology and routes of transmission. Epidemiologic Reviews 2000; 22: 283-297.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Graham DY, Klein PD, Evans DG, Feidorek SC, Evans DJ, Adam E, Malaty HM. Helicobactor pylori Epidemiology, relationship to gastric cancer and the role of infants in transmission. European Journal of Gastroenterology and Hepatology 1999; 4: 1-6.  Back to cited text no. 3    
4.Welsh KJ, Randolph JG, Ravitch MM. Editors (cited by Ternberg in Peptic Ulcer Acute and Chronic) Pediatric Surgery, 4' edition Year Book Medical Publishers 1986; 4: 815.  Back to cited text no. 4    
5.Lewis DC, Hodinott C. Complicated peptic ulcer disease in childhood an overlooked diagnosis. Br J Clin Pract 1991; 45: 65-7.  Back to cited text no. 5  [PUBMED]  
6.Dilek ON, Sekeer B, Dilek FH, Omer AF. Perforated Gastric ulcer in children: Case Report Acta Chir Belg; 1995, 95: 182-3.  Back to cited text no. 6    
7.Torres J, Perez-Perez G, Goodman KJ, et al. A Comprehensive Review of the Natural History of Helicobactor pylori Infection in Children. Archives of Medical Research 2000; 31: 431-69.  Back to cited text no. 7    
8.Kovalkov VE, Krasiuk BM, Kulikovskii VE, Snitkin NA. Surgical compications of peptic ulcer in children and adolescents. Vestnik Khirugii Imeni i-i Gredova 1991;146: 67-8  Back to cited text no. 8    

Correspondence Address:
Asal Izzidien Al-Samarrai
Department of Surgery, Prince Charles Hospital Merthyr Tydfil CF47 9DT, Wales
United Kingdom
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Source of Support: None, Conflict of Interest: None

PMID: 19861827

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